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Early or delayed parenteral nutrition for infants: what evidence is available?
Kwi Moon1,2,3, Shripada C Rao2,4
1Pharmacy Department, Perth Children's Hospital, Nedlands.
Insights
Early parenteral nutrition benefits very premature infants, but high amino acid doses should be avoided. For older infants, delaying parenteral nutrition may be preferable to reduce infection risks, while monitoring key metabolic indicators is crucial.
Area of Science:
- Neonatal nutrition
- Pediatric intensive care
- Clinical evidence synthesis
Background:
- Parenteral nutrition (PN) is critical for infants unable to tolerate enteral feeding.
- Optimal timing for initiating PN in different infant populations remains debated.
- Evidence synthesis is needed to guide clinical practice regarding PN commencement.
Purpose of the Study:
- To review current evidence on early versus delayed parenteral nutrition initiation in infants.
- To evaluate the benefits and risks of early PN commencement across various infant age groups.
- To provide evidence-based recommendations for PN timing in neonates and children.
Main Methods:
- Systematic review of existing literature on parenteral nutrition timing.
- Analysis of recent multicentre randomized controlled trials in premature infants and older children.
- Evaluation of clinical outcomes including growth, metabolic complications, and infection rates.
Main Results:
- Early PN commencement improves physical growth in very premature infants (<32 weeks gestation).
- High early amino acid doses (>3.5 g/kg/day) may cause adverse metabolic effects.
- Delayed PN (beyond 24 hours) in full-term infants/children may increase infection risk and ventilation duration, but very early initiation can risk hypoglycemia.
Conclusions:
- Early PN is beneficial for very premature infants, with caution regarding high amino acid doses.
- For moderate to late preterm infants, PN initiation after 72 hours of untolerated enteral feeds is reasonable.
- Delayed PN (beyond 24 hours) is preferred for full-term and older infants, with careful monitoring of glucose and phosphate levels.
Purpose Of Review:
To review the current evidence evaluating early versus delayed commencement of parenteral nutrition in infants.
Recent Findings:
Recent studies in very premature infants (<32 weeks gestation) have shown that early commencement of parenteral nutrition immediately after birth improves physical growth. However, there are concerns that early use of very high dose of amino-acids (>3.5 g/kg/day immediately after birth) may cause metabolic acidosis, elevated blood urea, slower head growth and refeeding-hypophosphatemia syndrome. A recent multicentre randomized controlled trial found that commencement of parenteral nutrition within 24-h of admission increases the risk of infections and prolongs the duration of ventilation and ICU stay in full-term neonates, older infants and children. The study also found that delaying to day 8 of admission increased the risk of hypoglycaemia.
Summary:
Benefits of commencing parenteral nutrition on the first day of life appear to outweigh risks in very premature infants; however, it is prudent to avoid early very high doses of amino acids (>3.5 g/kg/day) in the first few days of life. In moderate to late preterm infants, if enteral feeds are not tolerated by 72 h, it is reasonable to commence parenteral nutrition. In full-term and older infants, it is preferable to avoid parenteral nutrition within 24 h of admission and consider delaying by further few days. Diligent monitoring of blood glucose, serum phosphate and other parameters is essential while on parenteral nutrition.
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